Symptom-Based Versus Laboratory-Based Diagnosis of Five Sexually Transmitted Infections in Female Sex Workers in Iran
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Among 1337 Iranian adult female sex workers in 2015, we assessed the diagnostic value of 4 self-reported sexually transmitted infection (STIs) symptoms for detecting laboratory-confirmed gonorrhea, chlamydia, trichomoniasis, human papillomavirus (HPV), and syphilis. While 37.7% reported vaginal discharge (VD), 25.9% reported pain or burning (P/B), 3.0% reported genital ulcers (GU), and 1.4% reported genital warts (GW), the prevalence of laboratory-confirmed syphilis, gonorrhea, chlamydia, trichomoniasis, and HPV was 0.4, 1.3, 6.0, 11.9, and 41.9%, respectively. The sensitivity of VD was 40.3% for detecting tricomoniasis, 37.5% for chlamydia, and 37.5% for gonorrhea. The sensitivity of P/B ranged from 12.5% for gonorrhea to 25.2% for trichomoniasis. The sensitivity of GU and GW was very low for 5 STIs. The sensitivity of all symptoms combined was also lower than 50%. Among asymptomatic participants, 41.2% tested positive for HPV, 11.8% for trichomoniasis, and less than 6.6% for other STIs. Symptom-based case management and surveillance of STIs can lead to misclassification of a large proportion of cases.
KeywordsSexually transmitted infections Symptoms Diagnostic values Female sex workers
The authors thank Dr. Parvin Afsar Kazerooni for her insightful comments on original draft of this paper. We would like to acknowledge supervisors and field staff from all collaborative universities who provided inputs to the study design and methods, assisted in data collection and implementation of the survey. Our gratitude also goes to the FSW who participated in the survey.
The study was funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria through UNDP Iran, and by Ministry of Iran. For this paper, we also received support from the University of California, San Francisco’s International Traineeships in AIDS Prevention Studies (ITAPS), U.S. NIMH, R25MH064712.
Compliance with Ethical Standards
Conflict of interest
All authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study. The study was anonymous, and no identifying information was collected during recruitment, informed consent, interview, or STIs testing. A unique identification code was provided to participants to help link survey responses to their test results. Participants were able to receive their STIs test results, post-test counseling, and referrals from the local testing and counseling center by providing their unique identification code. FSWs were given 70,000 Rials (equal to ~ 2.5 USD) as an incentive for participating in the study and 30,000 Rials (equal to ~ 1 USD) if they returned to receive their test results. The study protocol was reviewed and approved by the Ethics Committee of Kerman University of Medical Sciences (Ethical Code: K/93/209).
- 1.Newman L, Rowley J, Vander Hoorn S, Wijesooriya NS, Unemo M, Low N, et al. Global estimates of the prevalence and incidence of four curable sexually transmitted infections in 2012 based on systematic review and global reporting. PLoS ONE. 2015;10(12):e0143304.CrossRefPubMedPubMedCentralGoogle Scholar
- 2.World Health Organization. Report on global sexually transmitted infection surveillance 2015. Geneva; 2016.Google Scholar
- 9.World Health Organization. Report on global sexually transmitted infection surveillance 2013. Geneva; 2014.Google Scholar
- 10.Chen Y, Shen Z, Morano JP, Khoshnood K, Wu Z, Lan G, et al. Bridging the epidemic: a comprehensive analysis of prevalence and correlates of HIV, Hepatitis C, and syphilis, and infection among female sex workers in Guangxi Province, China. PLoS ONE. 2015;10(2):e0115311.CrossRefPubMedPubMedCentralGoogle Scholar
- 11.Kazerooni PA, Motazedian N, Motamedifar M, Sayadi M, Sabet M, Lari MA, et al. The prevalence of human immunodeficiency virus and sexually transmitted infections among female sex workers in Shiraz, South of Iran: by respondent-driven sampling. Int J STD AIDS. 2014;25(2):155–61.CrossRefPubMedGoogle Scholar
- 12.Roksana J, Fatemeh A. An overview on sexually transmitted infections in Iran. Int J Reprod Contracept Obstet Gynecol. 2016;5(3):585–95.Google Scholar
- 14.Shah NS, Kim E, de Maria Hernández Ayala F, Guardado Escobar ME, Nieto AL, Kim AA, et al. Performance and comparison of self-reported STI symptoms among high-risk populations–MSM, sex workers, persons living with HIV/AIDS–in El Salvador. Int J STD AIDS. 2014;25(14):984–91.CrossRefPubMedPubMedCentralGoogle Scholar
- 15.Kosambiya JK, Baria H, Parmar R, Mhaskar R, Emmanuel P, Kumar A. Diagnostic accuracy of self-reported symptomatic assessment versus per speculum/per vaginal examination for the diagnosis of vaginal/cervical discharge and lower abdominal pain syndromes among female sex workers. Indian J Sex Trans Dis. 2016;37(1):12.CrossRefGoogle Scholar
- 18.StataCorp. Stata statistical software: release 15 (Package DIAGT). College Station, TX: StataCorp LLC; 2017.Google Scholar
- 19.Shaukat S, Kazmi AH. Sexually transmitted infections and syndromic management. J Pak Assoc Dermatol. 2015;25:159–61.Google Scholar
- 25.Mirzazadeh A, Shokoohi M, Khajehkazemi R, Hosseini Hooshyar S, Karamouzian M, Fahimfar N, et al. HIV and Sexually Transmitted Infections among Female Sex Workers in Iran: Findings from the 2010 and 2015 National Surveillance Surveys. In: Conference SIA, editor. 21st International AIDS Conference; Durban: 21st International AIDS Conference; 2016.Google Scholar
- 28.Patterson TL, Volkmann T, Gallardo M, Goldenberg S, Lozada R, Semple SJ, et al. Identifying the HIV transmission bridge: which men are having unsafe sex with female sex workers and with their own wives or steady partners? J Acquir Immune Defic Syndr. 2012;60(4):414.CrossRefPubMedPubMedCentralGoogle Scholar
- 30.World Health Organization. Guidelines for the management of sexually transmitted infections. Geneva: World Health Organization; 2004.Google Scholar
- 32.Wariki W, Ota E, Mori R, Koyanagi A, Hori N, Shibuya K. Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low and middle income countries. Cochrane Database Syst Rev. 2012(2):No:CD005272.Google Scholar